Orthodontically induced inflammatory root … Resorption is a clinical condition associated with a physiological or pathological process leading to a loss of dentin, cementum and/or

DOI: 10.1051/odfen/2012402 J Dentofacial Anom Orthod 2013;16:102� RODF / EDP Sciences

1

Conflicts of interest declared by the author: NONEArticle received: 08-2012

Accepted for publication: 09-2012

Orthodontically inducedinflammatory root resorption:apical and cervical complications*

Dominique LUNARDI, Thibault BECAVIN,

Alain GAMBIEZ, Etienne DEVEAUX

ABSTRACT

External root resorption is a feared complication during orthodonticprocedures. It can affect both the apex, but also the cervical zone of the rootssubjected to orthodontic forces for tooth movement and can compromise thefuture of the involved teeth. The patient must be informed about the risks ofresorption as a consequence of orthodontic treatment. The detection ofresorptions can occur during and/or after the active phase of orthodontictreatment.Knowledge of the clinical situations predisposing the patient to resorption isessential. The data are still insufficient to avoid them completely. Early andprecise detection is essential, and the cone beam with its high resolution 3Dimages, can compensate for the diagnostic inaccuracy of digital panoramicand periapical films. There are treatment solutions and their prognosis iscorrelated to early detection. Apical resorptions, generally not infected, canmostly be stopped by discontinuing orthodontic forces. Cervical resorptions,with a bacterial component, will require surgical intervention with curettageand restorative build-up of the resorbed area. Current research, particularly ingenetics, is in the developmental stage. In the future, the conclusions of thisresearch will allow orthodontists to more precisely target at risk patients soas to avoid these complications.

KEY WORDS

Inflammatory root resorptions,

Apical resorption,

Cervical resorption,

Orthodontic treatment,

Risk factors,

Cone beam.

Address for correspondence:

D. LUNARDIFaculte de Chirurgie DentairePlace de Verdun59000 [email protected]*Translated from French by Patrick FinneganArticle available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2012402

http://www.jdao-journal.org

http://dx.doi.org/10.1051/odfen/2012402

INTRODUCTION

Resorption is a clinical conditionassociated with a physiological orpathological process leading to a lossof dentin, cementum and/or bonestructure7.

In orthodontics, therapeutic proce-dures mainly involve restructuringbone, periodontal ligaments and ce-mentum1. All orthodontic treatmentis accompanied by self-limiting andreversible micro-resorptions of rootand cementum. Histologically, theyare radiographically imperceptible sur-face resorptions, allowing and ac-companying dental movements19.According to Andreasen et al.2, thesesurface resorptions are followed byspontaneous repair with the forma-tion of new cementum. This isneither a physiological process nor apathological process but instead acontrolled orthodontic therapeuticprocess, as long as the dentin is notaffected.

In certain cases, the phenomenonis no longer self-limiting: i.e. when therepair of the cementum is disturbed.The action of the odontoclastsreaches beyond the cementum to theunderlying dentin. This is a pathologi-cal process because once the dentinis affected, it continues in an irreversi-ble manner. These resorptions can af-fect the tooth at the apex as well asthe neck. For non-infected apical re-sorption, even if the dentin cannot bereconstructed, newly formed cemen-tum can cover the resorbed area19.Resorption shortens the root. The

anatomy of cervical resorptions cre-ates a predisposition to breeding bac-teria at the resorption site. Because ofits invasive nature13, this situation pre-vents new cementum from forming.

Given the importance of preventingthese pathological resorptions, ortho-dontists must carefully take into ac-count risk factors and conditionsbefore initiating any treatment. Bytaking these precautions, orthodontictreatment can also be adapted tomore difficult clinical situations.

If this preventive strategy fails anddespite our efforts, invasive inflam-matory resorptions appear, theyshould be detected early and accu-rately. A new diagnostic tool, thecone beam, already extensively usedby endodontists, compensates forthe diagnostic inaccuracy of panor-exes and periapical radiography40.These two types of images do notclearly reveal resorption in all its con-figurations.

When this is the case, orthodon-tists and dentists must act in concertto set up a therapeutic strategy.

The earlier resorption is detected,the simpler the treatment solution isto safeguard teeth. A thorough follow-up during and after orthodontic treat-ment is therefore essential and itshould be part of a long-term plan. Infact, pathological inflammatory resorp-tions show up long after the end oftreatment and this is especially truefor external cervical resorptions13.

DOMINIQUE LUNARDI, THIBAULT BECAVIN, ALAIN GAMBIEZ, ETIENNE DEVEAUX

2 Lunardi D, Becavin T, Gambiez A, Deveaux E. Orthodontically induced inflammatory root resorption:apical and cervical complications

HOW DO EXTERNAL PATHOLOGICAL INFLAMMATORY ROOTRESORPTIONS DEVELOP?

Olivieri et al.29 explains that the de-velopment of external pathological in-flammatory root resorptions resultsfrom the alteration or loss of the pro-tective cementum layer due to in-flammation. The cementum protectsthe underlying dentin from resorptionand has the potential for repair30.When a stimulus attacks the cemen-tum and overwhelms its capacity forrepair, dentin is exposed11,13.

Histologically, the dentin exposureto osteoclast precursor cells, originat-ing in the periapical ligament and dif-ferentiating into odontoclasts, marksthe starting point of the pathologicalprocess11,13. In fact, only the cemen-tum has the potential for repair, andas soon as the dentin is attacked andis in turn resorbed, the loss of rootstructure becomes irreversible19.

The forces exerted during orthodon-tic treatment can, in certain cases,lead to this type of irreversible resorp-tion. The forces represent a potentialmechanical stimulus for pressure onthe cementum. Brezniak and Wasser-stein6, in 2002, suggested the use ofterminology specific to orthodonticsand spoke of orthodontically inducedinflammatory root resorptions (OIIRR),emphasizing the importance of thisphenomenon. In orthodontic literature,this is very often associated with thenotion of apical resorption, but weshould not forget that resorption canalso involve the cervical area. Heither-say shows in one research article13,

that the highest rate of cervical resorp-tion involved patients who had earlierorthodontic treatment. The anatomicalshape of the cervical resorption influ-ences their development. These cervi-cal resorptions are in effect subject,by way of the sulci, to a possiblebacterial infestation promoting inflam-mation and hence the development ofresorption, even if the movementforces are discontinued.

However, orthodontic forces arenot the only etiology likely to causedisturbance in cementum repair andsubsequently pathological root re-sorption.

It is important for the orthodontistto be aware of the possibility andnature of other possible causes of re-sorption. Therefore, they should alsobe listed as risk factors or additionaletiological factors to orthodonticallyinduced external root resorption.When diagnosing an external root re-sorption during or after orthodontictreatment, the practitioner can formu-late a differential or complementarydiagnosis.

Therefore, if Heithersay13 impli-cates orthodontic treatment in almostone fourth of recorded clinical casesof external cervical resorption, healso implicates traumas, internalbleaching, surgical and periodontalprocedures, and other factors suchas bruxism and delayed eruption ofthe dentition.

ORTHODONTICALLY INDUCED INFLAMMATORY ROOT RESORPTION: APICAL AND CERVICAL COMPLICATIONS

Rev Orthop Dento Faciale 2013;16:102. 3

WHAT ARE THE PREDICTIVE FACTORS FOR THE APPEARANCE OF ROOTRESORPTIONS IN ORTHODONTICS?

Mizrahi27 reminds us that ortho-dontic treatment, like any other pro-cedure of dentistry, exposes thepractitioner to possible litigation.

An analysis of the predictive fac-tors for the appearance of root re-sorption is indispensable beforebeginning orthodontic treatment andthese factors should be listed in theinformed consent form signed by thepatient6.

In fact, certain patients are morepredisposed than others to develop-ing root resorption during orthodontictreatment11 and it is crucial to informthem. From a medico-legal perspec-tive, Bery5 explains that the notion ofrisk is an integral part of patient infor-mation and that the practitionershould inform them about the knownrisks based on available scientificdata.

For OIIRR, these risk factors aregenerally related to the genetic pre-disposition of the patients or to theirgeneral overall health. They can belocal, depending on the patient’s priordental treatment. Finally, there arerisk factors specific to the orthodon-tic treatment to the teeth that are in-volved.

Genetic factors predisposing toresorption

In some ethnic groups, we find thesame susceptibility to orthodonticallyinduced resorption16. According toSameshima and Sinclair32, Hispanicpatients are more susceptible to re-sorption than Asian patients. Further-

more, Hartsfield11 explains that theactivation of the osteoclasts (resorp-tion cells) may be genetically linked.Iglesias-Linares et al. demonstratethat genetic variations involving theinterleukine-1ß gene (implicated inthe inflammatory process associatedwith orthodontic movements), mayexplain the appearance of certain ex-ternal apical resorptions. All these ar-ticles present a variety of findingsthat argue in favor of developing thisline of genetic research regardingOIIRR.

Risk factors related to thegeneral health of the patient

Chronic asthma and certain aller-gies can increase the chances thatOIIRR will develop.

Brezniak and Wasserstein6 reportthat patients with chronic asthma,whether treated or not, have a great-er susceptibility to apical OIIRR onthe upper molars. This occurs be-cause asthma allows the inflamma-tion of the sinuses to come intoclose contact with the apex of themaxillary molars and premolars.

Risk factors related to priordental procedures

For young patients, prior traumaticincidents are common and it is notunusual for them to have a history offractures, luxations and tooth loss fol-lowed by prosthetic replacement. Inaddition to any orthodontic treatment,



the traumatic incidents alone couldaccount for the appearance of inflam-matory root absorptions. But, incases of orthodontic treatment, theseteeth that have already suffered trau-ma or even perhaps have alreadybeen resorbed will be all the morevulnerable to the forces that they willundergo. Brezniak and Wasserstein6

recommend waiting at least 3months before exerting force on atransplanted or re-implanted tooth.However, in one study of the factorsthat predispose patients to cervicalresorption, Heithersay13 remarks thatthe etiological association of ortho-dontic-trauma is relatively rare (3% ofthe teeth studied). Nonetheless, to-gether, orthodontics and trauma arefrequently implicated in the etiologyof resorption. Heithersay’s findingsmight therefore be due the effectivecaution of orthodontists in applyingforce to move teeth that show signsof previous trauma.

Certain teeth whether traumatizedor not, must be treated endodonti-cally, and in the orthodontic literature,there are many debates aboutwhether these filled teeth are moresusceptible or less susceptible to re-sorption. There is no consensus aboutthis question and in fact, researcherseven arrive at contradictory findings.Mattison et al.26, and more recentlyEsteves et al.8 were unable to offerany evidence of significant differencesbetween live and filled teeth. Mah etal.22 show that orthodontically inducedapical resorptions are slightly greaterfor endodontically treated teeth evenif the difference is not statistically sig-nificant, whereas Bender et al.4 arriveat the opposite conclusion. Based onour current understanding, we should

use the same approach to vital andnonvital teeth in the context of ortho-dontic treatment, except if the endo-dontic treatment is associated withsome previous trauma. Nonetheless,faced with all these contradictions,Iglesias-Linares et al.4 opened up newperspectives for research concerningendodontically treated teeth by focus-ing on the genetic component, espe-cially interleukine-1ß.

For teeth that have undergone in-ternal bleaching, the risk for resorp-tion is described separately from anyorthodontic treatment. Similar to trau-mas, in the case of orthodontic treat-ment, the risk for resorption of atooth that has undergone an internalbleaching will be greater. However,this conclusion needs to be qualifiedsince oxygenated water and the cata-lyst effect of heat due to frictionwere essentially implicated in thephenomenon of resorption afterbleaching pulp-free teeth. The pre-sent use of sodium perborate mixedwith water is a much safer procedureand less likely to induce resorption.

Other currently used therapeuticprocedures that may have damagedthe cementum of one or more teethmay be listed in the medical historyof the patient and can representareas at risk for resorption. Surgicalprocedures can, for example, be-cause of trauma inflicted on neigh-boring teeth during manoeuvers forextraction (luxating and elevating withforce), may be the cause for collat-eral trauma to cementum. Even ifyoung patients are much less in-volved, periodontal detachment canalso cause damage to the cementumand induce secondary external cervi-cal resorption.



The risk factors associated withorthodontic treatment and thetreated teeth

All categories of teeth do not seemto have the same susceptibility to re-sorption. In his thesis, Makedonas23

refers to a number of studies andconcludes that maxillary incisors, andmore particularly lateral incisors aremore frequently affected by ortho-dontically induced apical resorption.Apices that are either blunt or drop-per-shaped present a greater degreeof resorption compared to normallyshaped apices. Next, he mentionsthe vulnerability of the lower incisorsand the upper premolars.

The root anatomy must also be con-sidered as a factor. Lavander and Mal-mgren17 studied the relationship ofthe shape of the root to the incidenceof apical resorption. Apices having thin‘‘pipette-like’’ or blunt shapes had agreater degree of resorption than nor-mally shaped apices.

There is a debate as to whether ornot orthodontic forces alone causeroot resorption. Should the appliedforces be below a threshold so as toavoid resorption? Lopatiene andDumbravaite19 attempt to answerthis question and agree on forces of7 to 26 g/cm2. Maltha et al.28 confirmthat the magnitude of the force ex-erted is a decisive factor and that itsintermittent application causes lessdamage than when it is continuous.Esteves et al.8 are in agreement andthink that the use of intense force in-creases the likelihood of orthodonti-cally induced resorption.

When inflammatory resorption isinduced by orthodontictreatment, when does it appearand what forms does it take?

Resorption resulting from the forceof orthodontic traction can occur onthe apex as well as the cervical zone.

Apical resorption can appear duringthe active phase of orthodontic treat-ment and this is why the term resorp-tion in orthodontics is often closelyassociated with the apex. Orthodon-tists diagnose them while performingroutine radiographical examinationsoccurring periodically during the activephase of treatment. The 6-9 monthperiod after beginning treatmentseems to be important for screeningand detecting apical resorption17,19.The detection of minor resorptions atthis time would confirm that there is ahigh risk for subsequent aggravationof this phenomenon19.

As for cervical resorptions, theyare generally diagnosed much later.Heithersay13 diagnosed them in pa-tients whose orthodontic treatmenthad taken place 18 to 33 months ear-lier. Due to their late detection, theseresorptions are not observed by theorthodontist earlier. In fact, rarely dopatients subject themselves to regu-lar, long-term post-treatment screen-ings. External cervical resorptiondiffers also because of direct expo-sure to the oral environment andtherefore to bacterial infestation. Dueto this exposure, Heithersay12 is in-sistent about the invasive nature ofthese resorptions and describes theiraggressive behavior. However, their



progression is slow and their perfora-tion of the pulp only occurs whenthere are serious lesions. The dentinprobably contains an inhibitor for re-sorption39.

A system of classification for thevarious types of resorption makes itpossible to make a precise diagnosisregarding their degree of severity.

For apical resorptions, the Levan-

der and Malmgren system17 distin-guishes four levels of apical lesion(Figs. 1 and 2):

–level 1: the resorption is minimaland simply leaves an irregular apicalroot contour.

–level 2: the resorption lesion is nogreater than 2 mm on the hard tis-sues. The authors call it minor re-sorption.

–level 3: the resorption destroysup to the first third of the root. There-fore, the resorption is qualified as se-vere.

–level 4: the resorption extendsbeyond the first third of the rootlength and is now considered ex-treme.

For external cervical resorption,the Heithersay system of classifica-

tion distinguishes four levels of cervi-cal lesion (Figs. 3 and 4):

–level 1: the resorption is a smallinvasive cervical lesion that presentsa shallow dentinal erosion.

–level 2: the resorption lesion isvery limited and penetrates the den-tin close to the pulp chamber butdoes not extend as far as or onlyslightly onto the root dentin.

–level 3: the resorption lesion pre-sents a deep penetration into thedentin up to the first third of the root.

–level 4: the resorption lesion iswidely invasive and spreads apicallybeyond the first third of the coronalroot.

HOW TO DETECT OIIRR: INPUT FROM THE CONE BEAM

Root resorption presents a clini-cally discreet symptomatology, thatmay be entirely absent, especially inthe first stages of their development.

The clinical picture of an externalcervical resorption can be limited to asimple sensation of discomfort witha pinkish cervical discoloration uponexamination, whereas the clinical pic-ture for apical resorption can be to-tally asymptomatic.

Because early detection is so es-sential, it calls for regular comple-mentary radiographic examinations.The orthopantogram is currently usedto conduct examinations during the

course of treatment, but, even withperiapical films, the diagnostic accu-racy40 of this radiographic examina-tion is often limited.

Since the end of the ‘90s, a newtool has been available, known in theAnglophone world as CBCT20 or‘‘cone beam computed tomography’’scanner.

Scientific research that relies onCBCT for the study of orthodonticallyinduced root resorption is increas-ingly evident in the literature. Allthese studies confirm the reliabilityand accuracy of the high resolution3D images of the cone beam and



Figure 1The different levels of apical lesions (according to Levanderand Malmgren17).

Figure 2Orthodontically induced inflammatoryroot resorption on the upper rightlateral incisor: extreme apical lesion,level 4 Levander and Malgren17.

Figure 3The different levels of cervical lesions (according toHeithersay13).

Figure 4Orthodontically induced inflamma-tory root resorption on the upperleft second premolar: deep cervicallesion, level 3 Heithersay13.



show how valuable it is as a tool fordetecting resorption3,21,24,28.

The HAS10 in France (similar to theFDA) states that there is ‘‘a spatialresolution and reliability comparableto that of a scanner’’ (Fig. 5). TheHAS continues ‘‘the accuracy and re-liability of the measurements ofCBCT makes its use in the dento-maxillo-facial orthopedic discipline ap-propriate since the delivered radiationdose is less than that of a scanner’’.

The HAS report evaluates the ben-efits of new technology as they per-tain to each dental discipline.

In orthodontics, the conclusion ofthe report indicates that, for now,CBCT cannot be used in place ofconventional teleradiography for diag-nostic purposes. However, in endo-dontics, the report mentions that inthe interest of accuracy the conebeam should be used when informa-tion gathered from clinical examina-tions and radiography do not providesufficient data for diagnosis andtherefore a tridimensional image is in-dispensable. This statement appliesperfectly to the detection and diagno-sis of root resorptions (Fig. 6a to 6c).

Recently, Wang et al.38 studied invivo the accuracy of volumetric mea-surements of the cone beam on asampling of 27 maxillary and mandib-ular premolars. The authors concludethat the use of CBCT in the detectionof orthodontically induced root re-sorption is an obvious possibility.Lund20 demonstrates the existenceof resorption on both palatal and lin-gual surfaces. He also specifies thatthey would not have been detectedwith conventional radiography.

WHAT ARE THE THERAPEUTIC SOLUTIONS?

Therapeutic solutions are closelyrelated to both the location of the re-sorption (apical or cervical), and totheir stage of development (espe-cially for cervical resorption).

Throughout orthodontic treatment,the practitioner will most often en-counter apical resorption. In fact, it isespecially during the active phase oforthodontic treatment that resorption

appears. To the extent that routineradiographic screening is performed,the orthodontist is more likely to de-tect them at the initial point of theirdevelopment. This is why even if se-vere cases are detected, they are re-latively uncommon19. Sehr et al.33

examined a little more than 3000 pa-tients who underwent multi-brackettreatment between 1991 and 2010:

Figure 5Cervical resorption detected with cone beam imagingon a maxillary canine (transversal cut).



severe apical resorptions were de-tected in 16 patients. Makedonas23

confirms that the literature onlycomes up with an insignificant per-centage of moderate to severe casesof resorption.

When the first radiographic signsappear, it is advisable to temporarilyinterrupt orthodontic treatment for aperiod of 3 months31. In a survey ofrecent literature, Walker37 says thatstopping treatment for 2 to 3 monthsmakes it possible to completely re-duce the progression of root resorp-tion. Tirpuwabhrut et al.34 adopt thesolution of stopping treatment andconfirm that in instances of orthodon-tically induced resorption, the practi-tioner should, in this case, follow theprotocol essentially based on elimi-nating the causal factor, i.e. ortho-dontic displacements. The Norwegianauthors continue to state that in the

absence of infection (in other wordspulpal necrosis), endodontic treat-ment is absolutely useless and wouldeven be contra-indicated since theelimination of the pulp of a tooth dur-ing the resorptive process does notrestrict the development of resorp-tion. Routine clinical examination ofthe pulpal vitality of the treated teethis however essential, because evenif the pulpal disturbances are minimalwhen IOORR occurs34, the practi-tioner should never exclude the pos-sibility of necrosis. Other authorsrecommend the use of ultrasound oranti-inflammatory medication35. Thereis not a plethora of research in thisarea and it is difficult to determinethe best protocol. Once the resorp-tion process is stabilized, the practi-tioner can resume orthodontictreatment and cautiously monitor theresults by performing very precise

.Figures 6 a to 6ca: periapical view with suspicion of orthodontically induced external root resorption on a left upper canine;b: saggital cut with cone beam imaging: confirmation and precise imaging of cervical resorption;c: transverse cut with cone beam imaging: confirmation and precise imaging of cervical resorption.



radiographic examinations, particu-larly by the use of CBCT.

External cervical resorption is oftendetected after orthodontic treatmentis completed. According to Heither-say13, the detection can occur from1½ years to 33 years after orthodontictreatment. Therefore, most frequentlyeither a dentist or an endodontist willmake the diagnosis and choose thetherapeutic treatment for resorption.Based on their location, external cervi-cal resorption will be in direct commu-nication with the oral environment andhence will be rapidly invaded by thebacterial flora. Because of this infesta-tion, Heithersay14 emphasizes their in-vasive nature. This characteristic oftheir symptomatology differentiatesthem from apical resorptions, espe-cially regarding their development andtreatment. As soon as the first signsare detected either clinically or radiolo-gically, the practitioner should take aninterventionist therapeutic approach.Although the diagnosis is often maderadiologically, clinically a pink spot can

appear in the cervical area. This pink-ish discoloration signals the presenceof very vascularized granular tissueunder both the enamel and the dentinthat are eroded by resorption14

(Fig. 7). The intervention will thereforeconsist of (sometimes after lifting theperiodontal flap) a total elimination ofthe granulomatous tissue, followed bya reconstruction of the residual cavityof the resorption with either glass io-nomer or composite cement (MineralTrioxide Aggregate or BiodentineTM)(Fig. 8 a to 8d). This therapeutic ap-proach has four main objectives: tostop the process of resorption, to re-store the lost structure, to prevent arecurrence and finally to preserve es-thetics30. Vinothkumar et al.36 presenta clinical case where a Heithersay le-vel 2 resorption is treated surgically,and then restored using the reversesandwich technique combining com-posite and modified glass ionomerecement.

The decision for intervention de-pends on the extent of the lesion’sdevelopment and its placement onthe Heithersay scale14. For levels 1and 2 of resorption, Heithersay indi-cates that intervention is often theright prognosis since the pulp is stillprotected both by outer and innerdentinal walls. For level 3, the clinicalcondition is more complicated butintervention is still indicated9. How-ever, when the cervical lesion is level4, as long as it remains asympto-matic, Heithersay advises that thepractitioner withhold treatment (Fig. 9a and 9b). In fact, intervention at thisstage runs the risk of fracturing andtherapeutic failure that would requireremoval of the tooth. When level 4 isaccompanied by all signs and symp-toms, the tooth must be removed.

Figure 7Pinkish cervical discoloration indicating the presenceof an underlying external root resorption, on the leftlower second premolar.



CONCLUSION

The risk of orthodontically inducedroot resorption is a proven fact, but inmost cases, it can be controlled. Mostimportantly, the patient should be in-formed about the inherent risk of re-sorption. ‘‘It is better to informbeforehand than to be sorry after-wards when it is too late’’6. Therefore,it is important to screen for resorptionin every case but even more so for

high risk cases during both the activephase of treatment as well as afterthe end of treatment. This monitoringmust include both the apical and thecervical zones of the teeth subject toorthodontic forces. If there is suspi-cion of resorption, the cone beam is avery precise diagnostic referencepoint. It makes it possible to deter-mine the anatomical context, as well

Figures 8 a to 8da: residual cavity of resorption after eliminating pathological tissue, on the upper right lateral incisor;b: restoration with BiodentineTM cement;c: repositioning of the periodontal flap and sutures;d: cervico-coronary restoration using the sandwich technique with composite cement.



as the extent and severity of the re-sorption. Starting with an accurate di-agnosis makes the therapeuticmanagement easier for the practi-tioner.

Conservative therapeutic treatmentexists and resorting to extraction isstill the exception. For the orthodon-tist, it is essential to temporarily oreven indefinitely stop treatment incases of apical resorption in order tohalt the process of resorption. Incases of cervical resorption, the ortho-dontist should intervene as soon as re-sorption is detected given its invasiveand evolving nature when directly ex-posed to the oral environment. Ortho-dontists, dentists and endodontistswill have to collaborate in order to im-prove the prognosis of the most diffi-cult clinical situations.

Informing the patients and obtain-ing their informed consent, a thor-ough medical history and anevaluation of risk, routine screeningand early and accurate detection withthe use of cone beam technology,and finally, collaborative and multidis-ciplinary management of therapeutictreatments therefore represent thekey elements for the management oforthodontically induced apical andcervical resorptions. However, pre-sently, we are still unable to comple-tely eliminate the occurrence ofOIIRR even though Brezniak andWasserstein6 optimistically hope thatfuture research will make it possible.

AcknowledgementsWe wish to thank Remy Faucom-

prez for diagrams that appear in thisarticle.

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Orthodontically induced inflammatory root … Resorption is a clinical condition associated with a physiological or pathological process leading to a loss of dentin, cementum and/or

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